Anesth Pain Med 2018;13:222-231 https://doi.org/10.17085/apm.2018.13.2.222 Clinical Research pISSN 1975-5171ㆍeISSN 2383-7977 Preliminary study of anesthetic risk factors in surgery for pathologic fractures secondary to metastatic tumors Tae Kwane Kim, Jun Rho Yoon, Youngmyung Noh, Hye Jin Yoon, Received July 3, 2017 Mi Sun Park, and Young-hye Kim Revised ‌1st, September 13, 2017 2nd, October 2, 2017 Department of Anesthesiology and Pain Medicine, Bucheon St. Mary's Hospital, College of Accepted October 13, 2017 Medicine, The Catholic University of Korea, Seoul, Korea Background: Despite advances in the treatment of primary cancer, metastatic patho- logic fractures still affect the survival of cancer patients. The goals of surgery, such as those with terminal cancer, are to maintain a maximum level of independence and im- prove the quality of life. A patient may be a poor surgical candidate because of a short life expectancy or illness that is too severe to benefit from surgical fixation. Moreover, this surgery is an operation accompanied with significant morbidity and mortality. This retrospective study investigated the characteristics of these patients and assessed the influence of anesthetic risk factors on the outcome. Methods: The records of 45 patients with pathologic fractures who underwent surgical stabilization for metastatic factors from 1 January 1995 to 31 December 2013 at our hospital were reviewed. Demographic data, various severity scores, anesthetic factors, and survival were reviewed. Results: The most common sites of primary tumors were lung, liver and stomach. The Corresponding author predominant sites of pathologic fractures were the femur (71.1%); six lesions were in the Jun Rho Yoon, M.D., Ph.D. humerus and four in the spine. Univariate and multivariate analyses identified several Department of Anesthesiology and prognostic factors with a significantly worse influence on survival, including lung tumor Pain Medicine, Bucheon St. Mary's and Acute Physiology and Chronic Health Evaluation (APACHE) II score. Hospital, College of Medicine, The Catholic University of Korea, 327 Conclusions: Although the number of patients was too small to result in a satisfactory Sosa-ro, Wonmi-gu, Bucheon 14647, appraisal, the most important step is to select candidates to gain the benefits of pallia- Korea tive surgery. We suggest the possibility of APACHE II scoring and the recognition of lung Tel: 82-32-340-7075 cancer in making the clinical decision of performing the palliative osteosyntheses for Fax: 82-32-340-2255 patients with pathologic fractures. E-mail: [email protected] ORCID http://orcid.org/0000-0001-7457-7433 Key Words: Anesthesia, Cancer, Pathologic fracture, Survival. INTRODUCTION deposits and increase the probability of the occurrence of fractures [3]. The onset of pathologic fracture signals decreas- The skeleton is the third most common site of metastatic es the life span for patients with bone metastases in multiple cancer. One-third to half of all cancers metastasize to the tumor types [4,5]. Advances in therapeutic technology for skeleton [1,2]. Metastatic tumor cells that colonize the bone cancer have prolonged patient survival, which ironically has matrix tend to cause bone resorption at the sites of tumor cell increased the incidence of pathologic fractures [4]. This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. Copyright ⓒ the Korean Society of Anesthesiologists, 2018 222 Anesthetic risk for pathologic fractures Since tumor metastases reflect an advanced stage of dis- II, Logistic Organ Dysfunction score (LODS), and Charlson ease, patients with fractures through metastatic lesions are score to explore their correlation to the operation-related risk. often considered unsuitable for surgery [6]. However, the The result of surgery was graded as an unsuitable outcome outstandingly longer patient survival that has been achieved if any of the following three criteria were met: presence of makes conservative care no longer an acceptable option be- significant complications within 30 days postoperatively cause the patients are frequently bedridden, capable of only a which possibly result in serious morbidity, postoperative few simple social interactions, and in agony [6]. ICU admission exceeding 2 days, and death from operation The goal of palliative therapy is to lengthen the life span for fracture less than 6 months postoperatively. Accordingly, and relieve symptoms for the duration of the patient’s life patients were divided into the suitable and unsuitable group. without causing other symptoms [7]. Palliative surgery dif- Odds ratio (OR) comparisons included lung, liver, and stom- fers from other kinds of surgery in that most of candidates are ach tumors with the other tumors, femur fractures with other near the end of their lives and tend to become more physi- fracture sites, and general, combined general and regional, ologically compromised over time [8]. These surgeries tend and regional anesthesia. The cases were analyzed with re- to be performed aggressively [5,6]. The operation itself may spect to use of transfusion, intraoperative blood loss volume, shorten a patient’s life because of exacerbation of the primary operative time, and complications between both groups. tumor, postoperative complications, and the spread of me- Survival in days was calculated from the day of operation tastases. Furthermore, the anesthetic risk in palliative surgery to death. The day of death was determined from medical is considered higher than usual and anesthetic procedures charts and phone interviews until 31 December 2015. Clini- should be carefully applied [8,9]. cal characteristics were recorded as number (percentage) for The aim of this retrospective study was to investigate the categorical variables, and mean ± standard deviation for con- medical conditions of patients for palliative surgery and elu- tinuous variables. cidate anesthesia-related factors on outcome along with a Differences between the suitable and unsuitable groups literature review. were compared using the Wilcoxon rank sum test for con- tinuous variables and the chi-square or Fisher exact test for MATERIALS AND METHODS categorical variables. Univariable and multivariable logistic regression analyses were performed to identify independent Data were retrospectively collected by reviewing all the predictors of patients not suitable for surgery. Time to event charts of patients with known metastatic pathologic fractures (180-day death) analysis was performed using Cox propor- from 1 January 1995 to 31 December 2013. We identified all tional hazard regression and reported as hazard ratios (HRs) patients who underwent operations for pathologic fractures with 95% confidence intervals (CIs) and as Kaplan-Meier secondary to metastatic tumors during this period in our curves with a corresponding log-rank test. We checked pro- operating suites. All the medical charts were reviewed until a portional hazards assumptions with a test based on Schoen- minimum of two years or death after surgeries. The diagno- feld residuals. We selected variables for the adjusted multi- sis was intra- or postoperatively confirmed in all patients by variable analysis if their P value was < 0.050 in the univariable histopathologic examination. We collected data on age, gen- analysis. All statistical significance was determined by P < der, body mass index, origin of primary tumor, fracture site, 0.050. All statistical analyses were performed using SAS 9.3 visceral metastasis, therapeutic history, surgical time, blood (SAS institute Inc., USA). transfusion, net fluid balance, number of postoperative days in the intensive care unit (ICU), complications, and days to RESULTS death. We used a variety of severity scores, including the classifi- Forty five patients comprised 18 men and 27 women and cation of the American Society of Anesthesiologists, Eastern age range was from 40 to 96 years. The age distribution was General Cooperative Oncology Group performance status (ECOG), the 8th decade (n = 14), 7th decade (n = 11), 9th decade (n = Acute Physiology and Chronic Health Evaluation (APACHE) 10), 6th decade (n = 6), 5th decade (n = 3), and 10th decade (n www.anesth-pain-med.org 223 Anesth Pain Med Vol. 13 No. 2 = 1). The mean body mass index is 21.3. Lung, liver and stom- had 36 additional metastases in other organs, most often the ach carcinomas accounted for most of the primary lesions spine (n = 8) followed by rib (n = 4), brain (n = 3), and adrenal (Table 1). Primary cancer diagnosis was lung (n = 13), liver (n gland (n = 3) (Table 1). Before the time of fracture, 12 patients = 6), and stomach (n = 4). Fractures were most often located had received a surgical procedure to treat the primary tumor; in the femur (n = 32) followed by the humerus (n = 6) and ra- 11 patients had received chemotherapy and 7 patients had dius (n = 4) (Table 1). All fractures were treated with an inter- received irradiation (Table 1). nal fixation device or prosthetic implant. Twenty-two patients The distribution of American Society of Anesthesiologists physical status classification is 1 (n = 2), 2 (n = 13), 3 (n = 23), and 4 (n = 7). The distribution of ECOG performance status Table 1. Distribution of Factors scale is 0 (n = 10), 1 (n = 15), 2 (n = 11), 3 (n = 5), and 4 (n = Variable Number 4). The mean APACHE II score is 10.5, LODS score 3.42, and Primary cancer diagnosis Charlson co-morbidity index score 8.9. At review, 30 patients Lung 13 (66.7%) had expired within 2 years postoperatively. Average Liver 6 Stomach 4 postoperative survival was 621 days until 31 December 2015. MUO* 3 Of the deaths, seven men and seven women had died by 6 Thyroid 2 months postoperatively. The mean survival time was 355 Breast 2 Prostate 2 days for men and 798 days for women. This difference failed Cervix 2 to reach statistical significance (P > 0.050).